If South University nursing instructor Dottie Roberts were the czar of bone health in the United States, she’d have a clear recommendation for women in their 40s: Get your bone mineral density checked.
The advice would be a departure from today’s federal standards, in which Medicare provides little more than a nudge for women to undergo the bone health check at age 65. But Roberts’ thinking is that if osteoporosis and a precursor condition called osteopenia were diagnosed and treated earlier, the nation could save a lot of pain as well as billions of dollars in costs related to hip fractures.
The 2004 Surgeon General’s Report on Bone Health and Osteoporosis estimates the nation spends $18 billion a year on all fractures resulting from osteoporosis.
“When you’re 40 you can have screening for breast cancer,” says Roberts, a certified orthopedic clinical nurse specialist. “So why not do a bone mineral density test at that time?”
According to the National Osteoporosis Foundation (NOF), nearly 293,000 Americans age 45-plus were admitted to hospitals in 2005 because of a fracture of the hip’s femoral neck, and osteoporosis, or bone loss, was the underlying cause.
The NOF describes osteoporosis as a “major public health threat” for 44 million Americans or 55% of people age 50 and older. It’s not just a woman’s disease, although women suffer 76% of hip fractures, according to the U.S. Centers for Disease Control and Prevention.
The CDC also estimates that one in five people age 50-plus die in the first year following a hip fracture. A recent high-profile example: Author J.D. Salinger broke his hip in May 2009 and, despite returning to good health, passed away about seven months later.
That’s the bad news. The good news is hip fracture rates are declining. A study published last year in the Journal of the American Medical Association found that between 1985 and 2005, fracture rates dropped 32% for women and 25% for men in Canada. A 2007 study found a similar decline in the U.S. population.
In the 19 years since Roberts became a nurse, she has seen treatment of hip fractures improve dramatically. Now she’d like to see a leap in the prevention and treatment of bone loss. The problem, she says, is that osteoporosis doesn’t receive the same attention as a disease like breast cancer.
“Breast cancer is a very emotional disease,” says Roberts. “As a long-term orthopedic nurse, I am really sensitive to issues of osteoporosis, arthritis, and other things that don’t get the press that breast cancer gets. … I just think some of the figures that we have about the impact of orthopedic or musculo-skeletal conditions suggests that truly these are underappreciated problems.”
Several factors could be contributing to the reduction in hip fracture rates, though researchers are hesitant to draw firm conclusions. Among the possible explanations: increased awareness about the importance of calcium and Vitamin D in bone health; the development of drugs to treat bone loss; and the arrival of bone mineral density testing machines to diagnose osteoporosis and osteopenia.
Another possibility: Americans’ increasing girth might be serving as a cushion of sorts.
“I think the whole question of obesity and fractures is more complex than just how much you weigh, but I think that being very lean or very thin increases your risk of fracture,” says Dr. Ethel Siris, a past NOF president who is director of Columbia University’s Toni Stabile Osteoporosis Center in New York. While a large-boned person might be better protected, she explained, a small-boned woman who becomes obese in later life could suffer a more severe injury.
Siris and Roberts share a similar frustration that more efforts aren’t occurring on the front end. The Surgeon General’s report estimates that 4 in 10 women and 1 in 10 men age 50 and older will break a hip, spine, or wrist.
“What we can do right now is assess risk, and we’re not doing a very good job assessing who may be at risk of hip fracture,” says Siris. “Despite the fact that the ‘welcome to Medicare’ letter invites people to do a bone density test at age 65, only about 19 percent of women do it.”
Physicians likely are overwhelmed in 10-minute appointments with older patients suffering from obvious ailments like heart disease, she says. Given that osteoporosis is called the “silent disease” because there are no symptoms until a fracture occurs, a bone density test might not be a priority.
Since 2002, the U.S. Preventive Services Task Force has recommended routine osteoporosis screening for post-menopausal women age 65 and older and for age 60-plus women considered at risk. In 2008, the NOF recommended that screening begin for post-menopausal women age 50-plus with risks for osteoporosis and for at-risk men of the same age.
Though a hip fracture is no longer viewed as an automatic death sentence, it still strikes fear in older people, says Roberts, who is working on a doctorate in education at Nova Southeastern University in Florida.
Twenty years ago, patients faced traction and long hospital stays, she points out. Some succumbed to conditions related to spending months in bed, including blood clots and pressure sores. “It was terrible what happened before,” she says.
Today, patients are usually up and walking the day after “open reduction internal fixation,” the most-common surgery to repair a hip fracture, according to Roberts, who is also on staff at Palmetto Health Baptist in Columbia.
“I now do a pre-op class for patients, and I explain that the key is early ambulation,” says Roberts, who draws chuckles when she delivers this line, “You don’t come to the hospital to watch soap operas and eat bon-bons.” She then explains: "Every day you stay in bed you lose three days of stamina.”
Treatment of older and frailer patients, however, can present some ethical questions, said Roberts, who is about to publish an article in Orthopaedic Nursing titled “Violation of a Moral Rule: Care of the Patient Following Hip Fracture.” Roberts looks at the case of a 93-year-old patient with Alzheimer’s and the issues involved in an orthopedic surgeon’s decision not to repair her hip fracture.
Roberts’ work has been published in several orthopedic and medical-surgical publications, and she currently serves as an editor for MEDSURG Nursing: The Journal of Adult Health. Although she has earned a B.S. and M.S. in nursing, her first degree — a B.A. in English from the University of South Carolina — has come in handy, too.
“Nursing involves a lot of teaching,” Roberts says, “and the expertise in language has also stood me in good stead.”
Written by freelance talent for South Source.